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Editorial

Unruptured aneurysms

David G. Piepgras

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Jonathan A. Friedman and David G. Piepgras

Object

Vascular bypass is performed in neurosurgery for a variety of pathological entities, including extracranial atherosclerotic disease, extra- and intracranial aneurysms, and tumors involving the carotid artery (CA) at the skull base or cervical regions. Creation of an interposition saphenous vein graft (SVG) is the typical method of choice when the superficial temporal artery is not an option.

Methods

One hundred thirty consecutive patients treated with SVG between July 1988 and December 2002 at the Mayo Clinic were studied. A total of 130 procedures were performed in 130 patients. The indications were intracranial aneurysm in 51 patients (39%), CA occlusive disease in 36 (28%), extracranial CA aneurysm in 17 (13%), tumors involving the cervical CA in 11 (8%), vertebral artery occlusive disease in eight (6%), and other indications in six patients (5%). Among patients treated for intracranial aneurysms, 43 harbored giant aneurysms (> 25 mm in widest diameter) whereas the remaining eight patients harbored aneurysms that were large (15–25 mm in widest diameter). Among patients with CA occlusive disease, high-grade stenosis at the CA bifurcation was present in 29 and CA occlusion was demonstrated in seven.

Conclusions

The use of SVG bypass remains a valuable component of the neurosurgical armamentarium for a variety of pathological entities. Despite a general trend toward decreased use because of improved endovascular technology, surgical facility with this procedure should be maintained.

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Ashvin T. Ragoowansi and David G. Piepgras

✓ The case of an ectopic craniopharyngioma arising from a seed of tissue deposited along the operative track is reported. The uniqueness of this lesion is addressed. Ideal therapy and controversies regarding radiation therapy of craniopharyngiomas are discussed in light of this new variation in recurrence.

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David G. Piepgras, Vini G. Khurana, and Douglas A. Nichols

✓ The authors describe a unique clinicopathological phenomenon in a patient who presented with an unruptured giant vertebral artery aneurysm and who underwent endovascular proximal occlusion of the parent artery followed, several days later, by surgical trapping of the aneurysm after delayed subarachnoid hemorrhage (SAH). The intraoperative finding of a thrombus extruding from the wall of the aneurysm at a site remote from the origin of the SAH underscores the possibility that occult rupture of an aneurysmal sac can occur in patients with thrombosed giant aneurysms.

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Vini G. Khurana, David G. Piepgras, and Jack P. Whisnant

Object. The present study was conducted to estimate the frequency and timing of rebleeding after initial subarachnoid hemorrhage (SAH) from ruptured giant aneurysms.

Methods. The authors reviewed records of 109 patients who suffered an initial SAH from a giant aneurysm and were treated at the Mayo Clinic between 1973 and 1996. They represented 25% of patients with giant intracranial aneurysms seen at this institution during that 23-year period. Seven of the patients were residents of Rochester, Minnesota, and the rest were referred from other institutions. The aneurysms ranged from 25 to 60 mm in diameter, and 74% were located on arteries of the anterior intracranial circulation. The cumulative frequency of rebleeding at 14 days after admission was 18.4%. Cerebrospinal fluid drainage, cerebral angiography, and delayed aneurysm recurrence were implicated in rebleeding in some of the patients. Rebleeding was not precluded by intraaneurysm thrombosis. Among those who suffered recurrent SAH at the Mayo Clinic, 33% died in the hospital.

Conclusions. Rebleeding from giant aneurysms occurs at a rate comparable to that associated with smaller aneurysms, a finding that should be considered in management strategies.

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David G. Piepgras, Vini G. Khurana, and Jack P. Whisnant

Object. This retrospective study was made to determine the relationship between surgical timing and outcome in all patients with ruptured giant intracranial aneurysms undergoing surgical treatment at the Mayo Clinic between 1973 and 1996.

Methods. The authors studied 109 patients, 102 of whom were referred from other medical centers. The ruptured giant aneurysms were 25 to 60 mm in diameter. One hundred five of the patients survived the rupturing of the aneurysm to undergo operation, with direct surgery possible in 84% of cases. Excluding delayed referrals, the average time to surgery after admission to the Mayo Clinic was approximately 4 to 5 days. Patients admitted earlier tended to be in poorer condition, often undergoing earlier operation. On average, surgical treatment was administered later for patients with ruptured aneurysms of the posterior circulation than for those with aneurysms in the anterior circulation. Temporary occlusion of the parent vessel was necessary in 67% of direct procedures, with an average occlusion time of 15 minutes. Among surgically treated patients, a favorable outcome was achieved in 72% harboring ruptured anterior circulation aneurysms and in 78% with ruptured posterior circulation lesions.

Conclusions. The overall management mortality rate was 21.1%, and the mortality rate for surgical management was 8.6%. The authors believe that because of the technical difficulties and risk of rebleeding associated with ruptured giant intracranial aneurysms, timely referral to and well-planned treatment at medical centers specializing in management of these lesions are essential to effect a more favorable outcome.

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Vini G. Khurana, David G. Piepgras, and Jack P. Whisnant

Object

The present study was conducted to estimate the frequency and timing of rebleeding after initial subarachnoid hemorrhage (SAH) from ruptured giant aneurysms.

Methods

The authors reviewed records of 109 patients who suffered an initial SAH from a giant aneurysm and were treated at the Mayo Clinic between 1973 and 1996. They represented 25% of patients with giant intracranial aneurysms seen at this institution during that 23-year period. Seven of the patients were residents of Rochester, Minnesota, and the rest were referred from other institutions. The aneurysms ranged from 25 to 60 mm in diameter, and 74% were located on arteries of the anterior intracranial circulation. The cumulative frequency of rebleeding at 14 days after admission was 18.4%. Cerebrospinal fluid drainage, cerebral angiography, and delayed aneurysm recurrence were implicated in rebleeding in some of the patients. Rebleeding was not precluded by intraaneurysm thrombosis. Among those who suffered recurrent SAH at the Mayo Clinic, 33% died in the hospital.

Conclusions

Rebleeding from giant aneurysms occurs at a rate comparable to that associated with smaller aneurysms, a finding that should be considered in management strategies.

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Bahram Mokri, David G. Piepgras, and O. Wayne Houser

✓ Traumatic dissections of the extracranial internal carotid artery (ICA) in 18 patients aged 19 to 55 years were studied. All had suffered blunt head or neck injury of marked or moderate severity; motor-vehicle accidents were the leading cause of the injury. Delayed focal cerebral ischemic symptoms were the most common presenting symptoms. Less commonly noted was focal unilateral headache associated with oculosympathetic paresis or bruit. Following a head injury, the abrupt onset of focal cerebral symptoms after a lucid interval should raise the suspicion of arterial injury, particularly when computerized tomography fails to show abnormalities that would explain the evolving neurological deficits on the basis of direct trauma to the brain. Unilateral headaches, oculosympathetic palsy, and bruits also help in establishing the diagnosis. Focal cerebral ischemic symptoms may develop months or years after the initial trauma. These delayed symptoms are caused by embolization from a thrombus within a residual dissecting aneurysm. Common angiographic findings, in decreasing order of frequency, are: aneurysm, stenosis of the lumen, occlusion, intimal flap, distal branch occlusion (embolization), and slow ICA-to-middle cerebral artery flow. Although two patients died as the result of massive cerebral infarction and edema and some were left with severe neurological deficits, most made a good recovery. Residual dissecting aneurysms and occlusion seem to occur more frequently with traumatic dissections than with spontaneous dissections of the extracranial ICA.

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Thoralf M. Sundt Jr. and David G. Piepgras

✓ The results, complications, and technical aspects of occipital to posterior inferior cerebellar artery (PICA) bypass surgery are reviewed. Patients were divided into two groups: those considered to be a high risk for posterior circulation infarct but not disabled by the symptoms or deficits (eight patients), and those moderately or severely disabled at the time of admission (eight patients). Postoperative angiography revealed that 15 of the 16 grafts were patent. In 10 of the 15 patent grafts, the bypass graft served as a sole or major blood supply of the vertebral basilar system; in five patients, flow was limited to the distribution of the PICA. Eight patients achieved full employment or normal activity, six were improved but did not return to full employment, and two patients were unchanged. Ataxia was the major residual deficit in these patients.